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18 October, 2014

The complexity of mental illness

There has been a strong political focus recently on mental health, with pledges to reduce waiting times for those in need of interventions and to put mental illness on a par with physical illness. There is also a movement to change people’s perception of mental illness, thus reducing stigma and enabling people to talk about and understand mental illness in the same way that they do physical illness. These moves have sprung from people having to wait many weeks before receiving treatment for mental disorders, with this, on occasion, resulting in suicide as patients despair of ever receiving help.

All of this is very laudable. It will be wonderful if we can reduce the stigma and get people talking about, rather that shying away from, mental health issues. However, I have experience of mental illness from a rather different angle, an angle that people may be less familiar with. One of my close relatives has suffered from schizophrenia—one of the most serious mental illnesses— for the whole of their adult life. The symptoms of schizophrenia include delusions (of persecution, for example), auditory hallucinations (hearing voices), and disordered thought patterns. The delusions, in severe cases, become overwhelming and replace the sufferer’s ‘normal’, rational view of the world. It is not uncommon that people who suffer from schizophrenia also suffer from a complete lack of insight into their condition—their delusions appear so real to them that they are incapable of recognising that they are ill, a condition known as anosognosia. My relative falls into this camp.

For someone who recognises that they are ill and actively seeks help, there is a good chance of curing that person (or at least of controlling the symptoms of their illness). But for someone who cannot recognise that they are ill, the outlook is much less bright. From my experience, try as you might, it is impossible to persuade someone with anosognosia that they need help. And suggesting to them that they are ill (or even failing to express agreement with their delusional beliefs) makes them extremely angry and, sometimes, violent. The situation becomes intractable.

What, then, happens in situations like these? Well, the simple answer is that nothing can be done, until the person exhibits behaviour that makes them a danger to themselves or others, at which point they can be detained under the Mental Health Act and forcibly treated. In these cases, pressure on the nearest relative becomes intense. (The ‘nearest relative’ is a legal term, defined in the Act, and it is not possible to stand down from the position of nearest relative.) The nearest relative is ‘consulted’ at every stage of the detention because, legally, someone cannot be detained under the Act without the consent of their nearest relative. But this process makes a mockery of the concept of ‘consent’ since, although the nearest relative has the right to object to the detention and, for example, discharge their relative from hospital, the responsible clinician can simply intervene if s/he believes this to be necessary (typically, if they consider the detainee to be a danger to themselves or others, which they have to be anyway in order to have been detained in the first place!).

As the nearest relative I found myself in an impossible situation. My relative was clearly desperately ill and in need of help, but refused to accept this. My relationship with my relative was pretty much non-existent, as a result of the years that I had spent struggling to cope with their schizophrenia. My relative demanded that I object to their detention under the Mental Health Act, which clearly I wasn’t prepared to do. The authorities persisted in demanding information from me about my relative’s condition and symptoms, information which I couldn’t provide because of my lack of a relationship with my relative. And, in all of this, no support whatsoever was provided to me, as the nearest relative.

So, my point is this: while it is entirely proper that we should provide help to people with mental health issues when they seek it, mental illness is so much more complex than this. There are a whole host of people who are ill but who do/will not seek help. What should we be doing for these people? And, perhaps even more importantly, what should we be doing for those individuals who are caught in the crossfire—usually relatives—for whom there is currently zero support or provision?